Title VI Complaint Form s2

Title VI Complaint Form

Title VI of the Civil Rights Act of 1964 states "No person in the United States shall, on the ground of race, color or national origin, be excluded from participation in, be denied the benefits of, or be subjected to discrimination under any program or activity receiving federal financial assistance." Two Executive Orders extend Title VI protections to Environmental Justice, which also protects persons of low income, and Limited English Proficiency (LEP).

Please provide the following information in order to process your complaint. Assistance is available upon request. Complete this form and mail or deliver to: Georgia Regional Transportation Authority, 245 Peachtree Center Ave, NE Suite 800, Atlanta GA 30303. Alternatively it can be faxed to (770) 334-5249 or emailed to [email protected].

1. Complainant's Name: ______2. Address: ______3. City : ______State: ______Zip Code: ______4. Telephone No. (Home): ______(Business): ______5. Person discriminated against (if other than complainant)

Name: ______Address: ______City: ______State: ______Zip Code: ______

6. What was the discrimination based on? (Check all that apply):

�Race/Color �National Origin �Sex

7. Date of incident resulting in discrimination: ______8. Describe the discrimination. What happened and who was responsible? For additional space, attach additional sheets of paper or use back of form.

9. Did you file this complaint with another federal, state, or local agency, or with a federal or state court? (Check appropriate space) � Yes � No

If answer is yes, check each agency complaint was filed with: Federal Agency ______Federal Court ______State Agency ______State Court ______Local Agency ______Other ______Provide contact person information for the agency you also filed the complaint with:

Name: ______Address: ______City: ______State: ______Zip Code: ______Date Filed: ______Sign the complaint in space below. Attach any documents you believe supports your complaint.

______Complainant

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